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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002983
Report Date: 12/18/2024
Date Signed: 12/18/2024 08:41:15 PM

Document Has Been Signed on 12/18/2024 08:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:COUNTRY PALMS CARE HOMEFACILITY NUMBER:
397002983
ADMINISTRATOR/
DIRECTOR:		TRIPLETT, JOSEPH J.FACILITY TYPE:
740
ADDRESS:2905 BRISTOL AVENUETELEPHONE:
(209) 462-1135
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:B. ReyesTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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LPA Johnson arrived at the facility to conduct a POC visits.

The following deficiencies, initially cited during a visit on 10/24/2024, have been cleared:

Section Cited: 87303(e)(2)Date Due: 10/25/2024
Plan of Correction:
The facility will adjust the water temperature today to the required temperature. The facility will conduct water temperature logs for one week to ensure the hot water temperature is within regulations and the hot water is properly circulated throughout the facility. 		Corrections:
Cleared By Visit		Clearance Date:
12/18/2024
Section Cited: 87411(c)(1)Date Due: 10/31/2024
Plan of Correction:
Administrator shall call the first aid vendor and requested a New Card or send by email proof. Administrator will send a copy of First Aid card to LPA. FAX (916) 263-4744		Corrections:
Cleared By Visit		Clearance Date:
12/18/2024
Lisa RiosTELEPHONE: (916) 969-9685
Albert JohnsonTELEPHONE: (916) 217-1390
DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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